Sample Release Form

PARTICIPANT RELEASE OF LIABILITY

ASSUMPTION OF RISK AGREEMENT

***READ BEFORE SIGNING***

Organization Name:Tampa Bay Water Bike Company LLC (the "Host") Tampa, Florida

Participant Name(s) (Print):

In consideration of being allowed to participate in any way in the program, related events and activities, and use of equipment, I the undersigned, acknowledge, appreciate, and agree that:

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death.

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation.

3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately.

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESSthe Host, its officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and lessors of premises used to conduct the event (RELEASEES), from any and all claims, demands, losses, and liability arising out of or related to any INJURY, DISABILITY OR DEATH I may suffer, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

Health Statement

I will notify the Hostownership or employees if I suffer from any medical or health condition that may cause injury to myself, others, or may require emergency care during my participation.

Media Statement

By signing below, I hereby grant and convey to the Hostall right, title and interest in and to record my name, image, voice, or statements including any and all photographic images and video or audio recordings made by the Host.

I HAVE READ THIS RELEASE OF LIABILITY INCLUDING THE SAFETY CHECKLIST AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Participant’s Signature AgeDate

FOR PARENTS/GUARDIANS OF PARTICIPANT OF MINOR AGE (UNDER AGE 18 AT TIME OF REGISTRATION)

This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, to the fullest extent permitted by law.

Parent/Guardian Signature Date Emergency Phone Number(s)

SAFETY CHECKLIST

I have been offered a copy of a boaters safety guide to review before participating.

I have been given instruction on safe operation of a water bike.

I acknowledge that I am not currently intoxicated, and will not consume alcoholic beverages

or other intoxicating substances while on board.

A properly sized life vest has been fitted, and has been suggested to be used. I understand

that If I must keep it on the vessel at all times, and proceeding at my own risk if I choose not to wear it.

I have been instructed on proper use of my emergency whistle and how to properly utilize

hand signals for help.

I have been properly instructed on where I can safely operate a water bike and where I am

restricted to be on a water bike.

I understand that it is illegal to litter on the water, and I can be ticketed by local marine patrol.

I have prepaid for minutes, should I extend my time I understand I will be charged at a

rate of $1 per minute.

Additional Members in Group

Participant’s Signature AgeDate